Concomitant procedures using minimally access

Abstract

Alongside the mitral repair or replacement, a considerable number of concomitant procedures can be performed with the minimally invasive mitral valve surgical approach. Some of these concomitant procedures comprise the tricuspid valve repair or replacement, left atrial appendage (LAA) exclusion, Interatrial septum defects correction and atrial fibrillation (AF) ablation. annulus across the mitral isthmus ( Figure 4A), a line to the base of the LAA ( Figure 4B) and a line to complete the isolating box of the pulmonary veins ( Figure 4C). Depending on the size and anatomy of the left atrium, with 3 to 5 cryoablation lesion lines all the left Cox Maze lesion set can be accomplished ( Figure 4D). Bloodless field near the cryoablation probe during freeze phase is very important to achieve good transmural lesions and improved results. Special care should be observed when applying the freezing lesions to avoid proximity and injury to the phrenic nerve.After correcting existing PFO or ASD, LAA closing and eventual AF ablation, the mitral valve can finally be inspected and treated whenever possible with a mitral repair. Right atrium concomitant proceduresWhen right atrium approach is also needed the for the surgery, additionally to the standard femoral artery cannulation, the venous cannulation must accomplish isolated bi-caval drainage for bloodless surgical field within the right atrium as described previously in the topic "Cannulation techniques and the Vienna way".Usually the right atrium is opened after completing the left atrium procedures and closing the left atrium. A parallel to the septum right atriotomy is the most common incision although some surgeons prefer the oblique incision from the right atrial appendage to the inferior vena cava.To expose the right atrium, the same left atrium retractor can be used, preferably with a wider and shorter blade for optimal exposure. The tricuspid valve and the coronary sinus opening can easily be identified ( Figure 5).If a large ASD is present ( Figure 6A) and couldn't be closed from the left atrium, this defect can be corrected with direct oversewing or with a patch ( Figure 6B).Right atrium AF ablation can also be performed as a concomitant procedure and the lesions set can easily be achieved within the right atrium with cryoablation (4,5). The right atrium lesions lines must include a tricuspid line between the right atriotomy and the tricuspid annulus ( Figure 7A), a line to the superior and inferior vena cava ( Figure 7B,C) and a line to the right atrial appendage ( Figure 7D) (6). With 4 to 5 cryoablation lesion lines all the right Cox Maze lesion set can be accomplished ( Figure 7E). Again, a bloodless field is very important for better results and special care should be observed when applying the freezing lesions to avoid injury to the sinus node and the phrenic nerve.After correcting any ASD and eventual AF ablation, the tricuspid valve can finally be inspected and treated according to indication whenever possible with a tricuspid ring repair (Figure 8...